Racial and Ethnic Disparities in Peri-and Post-operative Cardiac Surgery

Purpose of Review Despite efforts to curtail its impact on medical care, race remains a powerful risk factor for morbidity and mortality following cardiac surgery. While patients from racial and ethnic minority groups are underrepresented in cardiac surgery, they experience a disproportionally elevated number of adverse outcomes following various cardiac surgical procedures. This review provides a summary of existing literature highlighting disparities in coronary artery bypass surgery, valvular surgery, cardiac transplantation, and mechanical circulatory support. Recent Findings Unfortunately, specific causes of these disparities can be difficult to identify, even in large, multicenter studies, due to the complex relationship between race and post-operative outcomes. Current data suggest that these racial/ethnic disparities can be attributed to a combination of patient, socioeconomic, and hospital setting characteristics. Summary Proposed solutions to combat the mechanisms underlying the observed disparate outcomes require deployment of a multidisciplinary team of cardiologists, anesthesiologists, cardiac surgeons, and experts in health care equity and medical ethics. Successful identification of at-risk populations and the implementation of preventive measures are necessary first steps towards dismantling racial/ethnic differences in cardiac surgery outcomes.


Introduction
Despite being a poorly defined social construct, race has emerged as a powerful risk factor in peri-and post-operative morbidity and mortality in cardiac surgery [1,2].While advancements in cardiac surgery have reduced morbidity and mortality, improvement in care has not been uniform across racial/ethnic groups [3,4].Though racial and ethnic Shane S. Scott and Doug A. Gouchoe contributed equally to the manuscript to be considered co-first author.Timothy M. Pawlik and Asvin M. Ganapathi contributed equally to the manuscript to be considered equal as senior author.minority groups are underrepresented in clinical trials and research studies, Black and Hispanic patients in particular have worse outcomes compared with White patients following cardiac surgery [3,5].These race-based differences have been attributed to a combination of patient characteristics [1,6,7,8], socioeconomic status (SES) [7,8,[9][10][11], clinical practices, cultural differences, hospital quality [7,8] and systemic issues (Fig. 1).Recent studies also suggest that disparities in cardiac rehabilitation may offer a potential explanation for differing outcomes due to underutilization of this life-saving therapy by racial/ethnic minority groups [12,13].However, even after accounting for these differences, a significant portion of race-based differences cannot be explained, thus warranting further investigation towards reducing racial/ethnic disparities in healthcare.The aim of this review is to highlight known racial/ethnic disparities in several cardiac surgical procedures including coronary artery bypass surgery (CABG), valvular surgery, cardiac transplantation, and mechanical circulatory support (MCS), and to describe their associations with peri-and post-operative morbidity and mortality.Of note, all referenced comparisons are to white individuals unless stated otherwise.Patient and hospital characteristics that impact post-operative outcomes among these patients are also documented.In addition, we explore factors that contribute to increased prevalence of disparities and propose potential solutions to help guide development of sustainable and equitable solutions.

Coronary Artery Bypass Graft (CABG)
While CABG remains one of the most effective treatments for coronary artery disease, several studies have demonstrated that racial background can significantly impact periand post-operative mortality in patients (Table 1) [7,8,14], with early mortality risk being 1.5 times higher for Black patients [15,16].A previous study using the Society of  Thoracic Surgeons (STS) National Database reported that Black race is an independent predictor of operative mortality during CABG [14].Unfortunately, these differences have persisted over the past few decades, despite improvements in operative techniques and adoption of more equitable practices.Additional studies using the Medicare database have noted that minority patients had a 33% higher risk-adjusted mortality rate after CABG [7].Amongst Veteran Affair's patients, individuals who identify as Black have even had higher mortality among low-risk patients, which was attributed to increased post-operative complications such as renal failure, respiratory complications, and bleeding [17].
A rigorous eighteen-year study by Becker and colleagues, with over five million patients, demonstrated that while inhospital CABG mortality dramatically decreased between 1988 and 2015, significant gaps persisted between Black males and other minority groups [3].Black male CABG patients had a 35.1% higher risk of in-hospital mortality.In contrast, after controlling for patient and hospital factors, Hispanic and Asian patients had significantly lower risks of in-hospital mortality.These data are supported by a recent meta-analysis that reported an increased risk of in-hospital mortality for Black patients [4], and a more recent STS study that demonstrated Black patients had higher in-hospital mortality (2.76% vs 2.19%) [18].These differences persisted following discharge as well, from 3-months up to 10 years post-CABG [3,15,19].Amongst Medicare patients, Black patients had higher 3-month and 1-year mortality [16].Gray et al. further demonstrated reduced survival among Black patients at 1-and 5-years post CABG, which persisted following adjustments for pre-operative factors [20].Supporting this finding, Cooper et al. noted that 3-, 5-, and 10-year survival for Black patients was lower [19].

Mechanisms Underlying Disparities in CABG
Studies seeking to explain the specific etiology of racial/ ethnic disparities in survival following CABG have noted that baseline patient characteristics [15], hospital quality [7,8,21], health insurance status [22], and SES [15,[22][23][24] all play a role.Higher prevalence of severe cardiovascular disease prior to CABG is one of the larger contributors of disparities in minority populations [7,16,25], as well as additional pre-operative comorbidities [7,18].However, these comorbidities in Black patients only explained less than 5% of racial/ethnic disparities in CABG survival outcomes [7].outcomes [8].In this study, Black patients had higher procedural mortality and morbidity, in part due to patient comorbidities, SES, hospital and surgeon effects (defined with respect to surgery volume and mortality risk ratios), as well as care factors (including use of internal mammary artery and perioperative medication use) [8].Even after accounting for these differences, Black race remained an independent predictor of worse outcomes [8].SES has also been considered a risk factor for poor mortality among CABG patients, as it impacts patient insurance status and hospital access [26].Regardless of race, Medicaid insurance was an independent risk-factor of mortality compared with private insurance and was reported to be associated with worse outcomes after isolated CABG [22].Coyan et al. also reported that following CABG, patients from lower income quartiles had an increased 5-year mortality [27].In a recent study, Hannan et al. evaluated the effect of area deprivation index, a granular measure of SES, on short-term CABG mortality.Patients from the most deprived areas had a higher in-hospital deaths following CABG, while Black, Hispanic and Medicaid patients were more likely to be readmitted [28].In addition, Black patients were more likely to be treated at hospitals with higher risk-adjusted mortality [8].Together, these studies suggest that poorer outcomes in Black and minority patients are in part due not only to patient factors but also environmental factors such as SES, insurance status and access to care.

Surgical Aortic Valve Replacement (SAVR)
Aortic stenosis (AS) is the most common valvular disease world-wide [29], and aortic valve replacement (AVR) is an effective therapy for relieving symptoms and improving survival [30].While the prevalence of AS in racial and ethnic minority patients is lower than Whites patients [31], following adjustment, surgical intervention, treatment rates and complications are significantly lower in minority patients [32,33].Even when afflicted with severe AS, Black patients are still less likely than White patients to undergo any type of AVR (Table 2) [34].While treatment rates in minority patients are lower, there are mixed survival outcomes.In previous studies, Yeung and colleagues demonstrated that while SAVR was less likely performed in Black patients, 3-year survival was similar [30].Similarly, McNeely et al. reported that while Black patients had higher 30-day readmission after SAVR, this did not impact mortality [35].In contrast, Ahmed et al. demonstrated that among Medicare beneficiaries, 1-year mortality was higher for Black patients, while Hispanic, Asian, and American Native patients had lower risk adjusted 1-year mortality [31].Supporting this finding, Li et al. demonstrated that post-SAVR, Black patients had higher in-hospital mortality [36].

Minimally Invasive Aortic Valve Surgery
The development of transcatheter aortic valve replacement (TAVR) has increased treatment options for patients with AS, and the number of aortic valvular procedures performed has drastically increased over the last decade.Several studies have demonstrated that racial and ethnic minority patients are underrepresented in TAVR procedures [10,36,37], with higher utilization and lower mortality rates among White recipients compared to racial/ethnic minority groups [38].In spite of this, following TAVR, Black patients have similar 30-day and 1-year survival, and clinical outcomes [37,39].In contrast, Alqahtani et al. reported that there was no significant difference in utilization among White and Black patients [40], while McNeely et al. demonstrated that likelihood of readmission or discharge to home after TAVR were not associated with race [35].Conversely, despite TAVR underutilization, Hispanic patients had higher in-hospital complications, prolonged length of stay, and increased hospital costs compared with Black and White patients [41].Americans Indians also had reduced survival post TAVR [42].Jaiswal et al. also demonstrated that following TAVR, Black patients are at higher risk of myocardial infarction and acute kidney injury [43].
There are only limited studies investigating racial/ethnic disparities in TAVR/SAVR outcomes among Asian and Native Americans.Li et al. reported that, like Black patients, Asian Americans were underrepresented in AVR, and despite having similar post-TAVR outcomes to Whites, Asian Americans faced greater risks of post-operative SAVR mortality and surgical complications [44].In the only study to evaluate disparities in TAVR/SAVR among Native Americans, Li et al. reported that these individuals were more likely to undergo SAVR than TAVR.Following propensity matching, however, Native Americans had five times higher stroke and three times higher venous thromboembolic events after SAVR [45].
Despite conflicting mortality results, these data demonstrate that Black patients had higher peri-and post-operative complications, which requires further interventions to address.As these studies focused on in-hospital or acute short-term mortality, further studies are needed to assess long-term mortality (> 5-years), and the underlying causes of the disparity in TAVR use.In addition, the limited data on Asian and Native Americans suggested a critical need for further studies to elucidate the progression of racial inequities and targeted actions to deliver equitable care [44,45].

Mechanisms Underlying Disparities in SAVR/TAVR
Racial/ethnic disparities in SAVR/TAVR are impacted largely by health insurance status, SES, and patient factors [46,47].In a cross-sectional study of Medicare beneficiaries that investigated whether TAVR/SAVR procedures are preferentially available to Whites patients, Gupta and colleagues reported that AVR within 6-months of AS admission is lower for Black, Hispanic, and Asian patients [48].In metropolitan US TAVR programs, following adjustments for age and comorbidities, zip codes with higher density of Black and Hispanic patients and individuals with greater SES disadvantages had lower utilization of TAVR [49].However, it is unclear whether these data reflect reduced incidence of symptomatic AS or disparate use of TAVR by minority groups, and therefore requires further study.In contrast, following adjustments for SES, Alkhouli et al. noted that 1-year adjusted mortality was similar among Black and Hispanic patients following TAVR, but lower among patients of Asian/Native American/Pacific Islander race [39].Together, these data suggest racial/ethnic disparities in access and post-operative management contribute to racial/ ethnic disparities in patients undergoing TAVR/SAVR.However, further studies are required to elucidate specific causes racial/ethnic disparities in TAVR/SAVR use.

Mitral Valve Surgery
Analogous to aortic surgery, White patients have a higher utilization of mitral valve surgery (MVS) or repair compared with Black patients (Table 3) [39,50].Early studies demonstrated that Black patients undergoing MVS were younger and had more comorbid conditions including diabetes mellitus, renal failure, congestive heart failure, endocarditis, and rheumatic disease [51].There were no differences, however, in postoperative complications and hospital mortality.In a subsequent study, Vassileva et al. also reported that racial and ethnic minority patients had a higher incidence of comorbidities, which resulted in prolonged hospitalization following MVS; however, no race-based differences in short-term mortality were noted [52].In a multicenter study, following adjustments for pre-operative factors, mitral etiology, and hospital quality, race was not associated with MVS complications or mortality.However, Black patients had increased utilization of extended care facilities and rates of readmission [53].
Race-based survival outcomes have also been reported among patients undergoing minimal invasive mitral valve surgery (MIMVS).In one study, Black and Hispanic patients undergoing transcatheter mitral valve repair had similar inhospital outcomes compared with White patients, except for higher incidence of vascular injury among Black patients [54].In a recent cross-sectional study, Glance et al. noted that Black individuals were less likely to undergo MIMVS, even after adjusting for patient risk, and had higher risk of in-hospital mortality and major complications [50].Black, White, Hispanic, and Asian patients who underwent transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation exhibit major differences in baseline characteristics and, intra-procedurally more devices were implanted in Black patients suggesting more advanced disease [55].At 1-year, both minority and Black patients experienced lower survival and increased heart failure hospitalizations [47].In an additional study, Black and Hispanic patients were less likely to undergo TEER, and Hispanic patients were three times more likely to experience in-hospital mortality after TEER than White patients [56].Supporting this finding, Sparrow and colleagues demonstrated that Black patients experienced a higher risk of in-hospital death, but similar overall incidence of post-procedural adverse events [11].

Mechanisms Underlying Disparities in Mitral Valve Surgery
Some of the potential processes driving these variations in clinical outcomes may be connected to hospital quality, SES, and insurance status.For example, Glance et al. reported that the infrequency of Black patients undergoing MIMVS was in part due to insurance status [50].Patients with commercial insurance had greater than two-fold higher odds of undergoing MIMVS than individuals with Medicaid insurance.Moreover, Black patients were more likely to have Medicaid insurance and undergo MIMVS at Low volume (LV) centers (< 20 cases) [50].Similarly, Steitieh et al. reported that racial/ethnic minorities, particularly Black and Hispanic patients, are less likely to undergo TEER at High volume (HV) centers [57].Interestingly, the authors also demonstrated geographic clustering of TEER centers, with a higher ratio of White patients in zip codes with HV TEER centers compared with LV TEER centers, which had a higher density of minorities [57].Differences in income and insurance status also impact survival outcomes among patients undergoing MVS (Table 3) [11,55,58].In early studies, Vassileva and colleagues demonstrated that Black and Hispanic patients undergoing MVS tended to be less affluent [44].Malas and colleagues investigated the influence of SES on survival after mitral repair among Medicare beneficiaries independent of race and ethnicity [58].Patients from distressed communities, which incorporates education level, poverty, unemployment, and housing security, were more likely to undergo surgery at LV centers and traveled further for surgical care.At 3-years, unadjusted survival and cumulative incidence of heart failure readmission were worse in patients from distressed communities.Community distress was independently associated with 3-year mortality and heart failure readmissions [58].This finding is supported by Shechter et al. who demonstrated that racial/ethnic minorities undergoing TEER were from lower SES areas, not fully insured, more often diagnosed with functional mitral regurgitation, and more often affected by biventricular dysfunction [55].Sparrow et al. also showed that patients with from lower SES (income quartile-1) had worse in-hospital outcomes, with increased cardiac and vascular events, compared with higher SES (quartile-4) [11].Unequal access to monitoring and preventive care based on race and SES is best exemplified by the higher use of urgent TEER among Black patients [59].Using NIS database, Spring and colleagues noted that Hispanic race, Medicaid insurance and patients with low incomes undergoing TEER have increased morbidity and mortality, prolonged length of stay, and increased hospital cost [59].As such, increasing access to private insurance and HV centers could improve minority patient outcomes in cardiac surgery.

Cardiac Transplantation
Several hundred-thousand people in the United States are currently living with end-stage heart failure for which transplantation is the only viable treatment option.However, only roughly 1% of these people end up being transplanted [60].This low percentage of transplantation utilization is due to several factors, including the lack of suitable donors.As such, this scare resource is only afforded to patients who qualify based on stringent guidelines, which are both subjective and objective [61].The subjective evaluation is mainly based on psychosocial requirements, suitable care, and support groups.Unfortunately, this subjectivity leaves much up for interpretation and unequitable decision making.
Though heart transplantation has drastically increased in use since its inception [6] and has improved in terms of patient outcomes and decreasing waitlist times -there are still challenges relative to making this treatment option equitable.Since 1987, there have been over 75,000 heart transplants in the United States, of which the vast majority have been White recipients (72%) [62].Over this time, Black recipients comprised 7% of total recipients in 1987, which has increased to 26% of total recipients in 2019 [62].Additionally, Hispanic patients make up ~ 8% of recipients [63].While Black recipients are becoming more represented within the transplant population, Hispanic patients are still under-represented.Heart transplantation inequities and disparate outcomes still persist, however, for Black recipients.A recent study by Cogswell et al. noted that Black patients have markedly lower rates of transplantation and have correspondingly increased waitlist mortality [64].Even in centers that serve racially and ethnically diverse populations, Black and Hispanic patients have a lower likelihood of receiving a transplant versus White patients [65].
Regarding mortality, a comprehensive UNOS analysis noted that White patients had much higher survival over the first several decades of transplantation .This mortality difference has subsequently subsided in recent years (2017-2020) [62].Moayedi et al. reported, however, that from 2013-2017 Black recipients experienced significantly higher mortality versus White recipients based on the Outcomes AlloMap Registry [1].Similarly, Chouairi et al. noted that Black and Hispanic recipients have an increased mortality following transplantation over a more recent time period (2011-2020), even after adjusting for the new allocation system that was implemented in 2018 [66].While the data are conflicting, more recent evidence supports that minority races have worse survival after heart transplantation [1,66].
While large database studies are important to study postoperative mortality, their lack of granular data makes it difficult to discern the reasons for these disparities amongst races.There is evidence to suggest that focusing on unique immunologic contributors to racial/ethnic disparities can help reduce graft failure and improve outcomes in heart transplantation [67].Prior studies demonstrate that immunologic factors confer the greatest risk for incident graft failure and is highest in Black population [68].Therefore, strategies to improve induction and maintenance of immunosuppression Black patients have been prioritized [2,15].Black and Hispanic recipients more often have public insurance and have end-stage renal disease at the time of transplant.Additionally, minority patients spend significantly longer on the waitlist [66].In general, Black patients also have higher risk of developing and succumbing to heart failure.Furthermore, Black patients are less likely to be under the care of a cardiologist, which may also contribute to these inequities [69].Another layer to this issue is the complex interplay of race and SES.Wayda et al. noted that recipients experiencing socioeconomic disadvantage and Black recipients had lower survival.Importantly, individuals living in the most disadvantaged areas had almost the exact same hazard ratio for mortality as Black patients [70].Recently, Azap et al. reported that high social vulnerability index (SVI) was independently associated with increased mortality following heart transplantation even if recipients survived at least one year [71] (Table 4).
The solution to eliminate these disparities are multifaceted and must tackle several social constructs [72,73].Though evaluating psychosocial factors is necessary for all transplant patients, it can add a certain amount of explicit or implicit bias to determine who is suitable for transplant.Breathett et al. conducted a national survey study of heart failure physicians (N = 422) and noted that even with identical clinical and psychosocial attributes, heart transplantation was less likely to be recommended to the Black patients due to concerns about trustworthiness and psychosocial factors [74].Thus, it is necessary to further study and carefully examine the process in which we determine whether or not someone is psychosocially fit for heart transplantation.Ultimately, transplant providers must make every effort to understand the causes behind disparities and issues surrounding the equitable use of heart allografts, as this is the best way to implement change.Previous studies have highlighted the importance of improving minority involvement within clinical trials [2], the number of diverse health care professionals within the medical field and finally improving social policies that may drive health disparities [66,67,75].

Durable Mechanical Circulatory Support
While the gold standard of treatment for end-stage heart failure is eventual transplantation, sometimes that is not feasible.With improvingly durable mechanical circulatory support (MCS), more patients who do not qualify for transplant are turning to MCS options.While Black adults currently make up around 12.1% of US population, these individuals currently represent around 29.5% of the adult heart failure population, and 27.5% of left ventricular device implantations (LVAD) [76].Though Black patients made up similar proportions of LVAD recipients compared with their prevalence of heart failure, these patients still received LVADs at a significantly lower rate versus White patients [76].Studies by Cascino et al. and others also noted a similar reduced utilization of all ventricular assist devices (VAD) among Black patients [77,78].In conclusion, similar to heart transplantation, providers must strive to eliminate bias, evolve psychosocial testing, and continue to study disparity related gaps in healthcare to make this therapy equitable for all (Table 5).

Future Directions and Strategies to Improve Cardiac Surgery Outcomes in Racial/Ethnic Minority Groups
With an increasingly diverse US population, cardiac surgeons must recognize and address drivers of racial/ethnic disparities in cardiac surgery (Fig. 1).Efforts should begin with addressing racial/ethnic minority representation in study populations and clinical trials [79,80].Recent assessment of racial minority representation in cardiac surgery randomized clinical trials (RCTs) by Cancelli and colleagues demonstrated that only 9 of the 51 RCTs published between 2000 and 2020 reported the race of enrolled participants [80].When reported, only 11.2% were non-White, despite racial/ethnic minorities comprising over 40% of US population.In a separate study, using  [81].Furthermore, Black (4%) and Hispanic (11%) patients were underrepresented, while Asian Americans (10%) were overrepresented.In addition to historical patient mistrust, rigid research design with restricted eligibility criteria, language, and education requirements, as well as limited outreach continue to perpetuate this disparity [2,77].Initiation of prospective registry-based studies [46] and prioritized recruitment of minorities [82,83] with culturally sensitive government mandates may improve understanding of specific causes of the race-based differences in outcomes.
Racial/ethnic minority groups also receive more urgent cardiac surgeries at LV facilities with higher risk of morbidity and death [59].Systematic employment of multidisciplinary teams involving cardiology, cardiac surgery, anesthesiology, critical care, medical ethics, and health disparity experts in safety net LV hospitals is another avenue to improve access and increase early referrals for minority patients.The greater ratio of LV centers to HV centers in disadvantaged regions provide historical evidence for their increased use by racial/ethnic minorities.Therefore, State, and Federal funding policies focusing on these LV safety net hospitals offers a chance for reform and better care for minority communities [84].In some reports, Black patients refused surgical interventions more often than Whites for certain procedures [30,85], which may highlight historic mistrust for the medical enterprise.Reduced offering of transplantation to the Black patients further highlights clinical implicit biases [74].The high level of Black and Hispanic readmissions for several cardiac surgery procedures also suggests disparate access to post-operative surveillance and preventive care [29,53,58].Increasing availability of cardiac rehabilitation therapy [12,13] for racial/ ethnic minorities especially those from low SES is essential to reducing disparate outcomes.Improving diversity of cardiac surgeons is also necessary for attenuating readmission and increase favorable patient outcomes.Research has demonstrated that racially diverse medical teams can improve multicultural care, which ultimately improves patient satisfaction [86].Given the perceived benefits of doctor-patient race concordance and culturally sensitive interactions on physician-patient communication, the fact that less than 3% of US cardiac surgeons are Black/African American, and 4% Hispanic may also impact racial/ethnic disparities [87].Towards equitable representation, coordinated efforts should be made to improve the mentoring pipeline and development of young aspiring cardiac and cardiothoracic surgeons from Black and Hispanic groups [87,88], which some organizations have done by creating scholarships and grants designed specifically for underrepresented minorities [89].

Limitations
There are limitations to this review.Though our literature review was broad and based on expert knowledge within this field of study, we undoubtably excluded studies that perhaps met inclusion criteria.In addition, due to the complex relationship between race and cardiac surgery outcomes, even in large multicenter studies, it is difficult to elucidate specific underlying causes of racial/ethnic disparities.Moreover, studies using populations with high-risk features may confound the effects of race, making it more difficult to assess the independent risks related to race [1].

Conclusions
The underlying etiology of racial/ethnic disparities in cardiac surgery is partly related to access to healthcare, lower incidence of utilization, disparate differences in income, zip code, surgeon bias, and hospital quality.Notwithstanding, intersectional considerations are limited.Therefore, large-scale national programs are necessary to dissect specific contributors.We recommend using a health equity lens to create an intervention framework that takes into consideration the impact of race/ethnicity, and interrelated variables towards reducing race-based mortality burden and improving care for all patients.Black, Hispanic, and Asian/North American Native patients had significantly lower adjusted treatment rates for aortic stenosis compared with Whites.Despite higher rates of hospitalization due to aortic stenosis among Black and Hispanic patients, the risk-adjusted 1-year mortality was higher for Black patients, while Hispanic, and Asian and North American Native patients were lower compared to Whites.The authors delineate the enduring racial and ethnic disparities in acute and long-term outcomes following aortic surgery.

Fig. 1
Fig. 1 Race and Ethnicity in Cardiac Surgery.Several factors including patient characteristics, clinical practice, systemic issues, hospital quality, socioeconomic status, and cultural differences have been shown to influence racial/ethnic disparities in cardiac surgery.Despite these barriers, proposed solutions require deliberate actions from cul-

Table 1
Racial and ethnic disparities in coronary artery bypass grafting *= This study did not provide aggregated sample size total for all 28 studies

Table 2
Racial and ethnic disparities in aortic valve surgery

Table 3
Racial and ethnic disparities in mitral valve surgery *This study evaluated race in multivariate analysis only

Table 4
Racial and ethnic disparities in cardiac transplantation

Table 5
Racial and ethnic disparities in mechanical circulatory support Becker ER, Granzotti AM Trends in In-hospital Coronary Artery Bypass Surgery Mortality by Gender and Race/Ethnicity --1998-2015: Why Do the Differences Remain?Journal of the National Medical Association 111:527-539.-Becker et al. demonstrated that racial disparities in CABG surgery still exist despite overall progress in reducing CABG surgery mortality across all groups in a national sample with over 5 million patients.Specifically, Black males had 35.1% higher adjusted in-hospital mortality following CABG, while Hispanic, and Asian-Americans had significantly lower mortality rates (-9.7% and -17.9% respectively) compared to White patients.Rangrass G, Ghaferi AA, Dimick JB (2014) Explaining Racial Disparities in Outcomes After Cardiac Surgery: The Role of Hospital Quality.JAMA Surg 149:223.-Rangrass et al. delineated the impact of SES, hospital quality and patient factors on racial disparities in cardiac surgery.Among Medicare enrollees between 2007-2008, risk-adjusted in-hospital mortality for nonwhite patients was 33% higher than White patients following CABG.However, hospital quality explained only 35% of the observed disparity, while 53% is explained by SES and hospital quality combined.Mehta RH, Shahian DM, Sheng S, O'Brien SM, Edwards FH, Jacobs JP, Peterson ED (2016) Association of Hospital and Physician Characteristics and Care Processes With Racial Disparities in Procedural Outcomes Among Contemporary Patients Undergoing Coronary Artery Bypass Grafting Surgery.Circulation 133:124-130.-Mehta et al. demonstrated that mortality and major morbidity rates after CABG are higher in Blacks than in Whites.Furthermore, Black race remained an independent predictor of outcomes even after adjusting for surgeon, hospital, and care processes in addition to patient and SES factors.Ahmed Y, Van Bakel PAJ, Hou H, et al (2023) Racial and ethnic disparities in diagnosis, management and outcomes of aortic stenosis in the Medicare population.PLoS ONE 18:e028181.-Ahmed et al. demonstrated disparate cardiac surgery utilization and outcomes among patients with aortic stenosis in a population-based cohort over 1.5 million Medicare beneficiaries between 2010-2018.
• • • • Glance LG, Joynt Maddox KE, Mazzefi M, et al (2022) Racial and Ethnic Disparities in Access to Minimally Invasive Mitral Valve Surgery.JAMA Netw Open 5:e2247968.-Glance et al. demonstrated that income and insurance type may contribute to racial/ethnic disparities in minimally invasive mitral valve surgery (MIMVS).While Black patients are less likely to undergo MIMVS, adjusted in-hospital mortality and inci-dence of a major complication was higher in Black patients compared to White patients.Furthermore, Black patients undergoing MIMVS are more likely to have Medicaid insurance and receive care from low-volume surgeons. •